京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第22044号 / 社医博第97号 / 新制||社医||10(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川上 浩司, 教授 福原 俊一, 教授 小池 薫 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Thesis (Master of Emergency Medical Care (MEMC))--Cape Peninsula University of Technology, 2019 / Introduction: Road traffic injuries are the ninth leading cause of death globally. Projections indicate that without new and sustained commitment globally to preventing such injuries, the situation will only worsen. Motor vehicle rescue does not lend itself to the prevention of road traffic incidents but through ensuring that all incidents are managed using sound evidence could contribute in positive outcomes for victims. It is unknown what contribution rescue education makes to the body of medical rescue knowledge in South Africa. Aims: The aim of this research was to investigate the relevance and scope of the principles of physics within medical rescue specifically in the context of motor vehicle rescue. It appears that current traditional methods of presenting rescue training, which is mainly procedural and technical, may contribute to 'segmented' learning. Research Methodology: Using an interpretive research design, multiple qualitative methodologies were employed. This methodological triangulation was intended to improve construct validity and trustworthiness of findings. A modified Delphi process through which questionnaires was repeatedly distributed to rescue experts was employed. Process tracing was used to evaluate the developed typical motor vehicle rescue case scenario narrative for underpinnings of the principles of physics. The Bachelor Emergency Medical Care Physics and Extrication subject guides was evaluated for its educational alignment during the document analysis. Legitimation Code theory as a theoretical framework was utilised to appraise the knowledge gap. Results & Discussion: Motor vehicle rescue incident may not always present in a similar manner due to various factors and influences. Development of the typical motor vehicle case narrative from which its physics principles could be identified was imperative. Most motor vehicle rescue related training occur with the vehicle in the upright orientation on all four wheels. This manner of frequent training may restrict rescue practitioners from moving beyond their 'typical' training knowledge when the situation presents a typical. The thematic document analysis of the BEMC Physics and Extrication subject guides lacked the necessary coherence which is required for a professional degree. It was deemed void of certain threshold concepts and structure which would allow the student to move between the theoretical and contextual knowledge. Motor vehicle rescue subject guides and most textbooks on the topic leaned towards a procedural and very technically detailed pedagogy, to the extent that it could contribute to segmented learning. Conclusion: Developing curricula that is underpinned by a theoretically sound evidence base would promote credibility of a qualification. Curricula by design inform the teaching, learning and the competencies which would ultimately be assessed. Professional degrees are intended to develop practitioners who would graduate with the knowledge and competencies to adapt to situations. In addition, graduate attributes of lifelong learning, reflective practice and the ability to contribute to the development of new knowledge is secondary to the goal of qualification attainment.

Betrachtet man die geschichtliche Entwicklung der Medizin in Europa und der arabischen Welt, so ist diese geprägt vom gegenseitigen Austausch und dem grenzübergreifenden Transfer von Wissen. In der frühislamischen Blütezeit legten arabische Wissenschaftler das empirische Fundament, auf dem heutzutage die moderne Schulmedizin fußt. Medizinische Werke, wie der al-qānūn fi cilm aṭ-ṭibb des Ibn Sīnā1 gelangten ins spätmittelalterliche Euro-pa, in dem die Wissenschaften unter dem Druck religiös motivierte Repressionen und aber-gläubischer Vorstellungen nahezu zum Erliegen gekommen war und blieben dort lange die einzige Grundlage für die theoretische Weiterentwicklung der Medizin2. Auf der Suche nach einer Thematik, die in Orient und Okzident gleichermaßen von Relevanz und präsent ist, um sie auf terminologischer und struktureller Ebene einander gegenüberzu-stellen, bot sich die Medizin daher als besonders geeigneter Untersuchungsgegenstand für eine solche Bestandsaufnahme, sprich für dieses Arbeit, an. Die darauf folgende thematische Eingrenzung war zu einem nicht unwesentlichen Teil beeinflusst und motiviert durch die Ausbildung und Berufserfahrung des Verfassers als Rettungssanitäter. Nichtsdestotrotz wurden persönliche Erfahrungen hier nicht als empirische Quelle missverstanden. Vielmehr wurden mit Rücksicht auf die wissenschaftliche Form und den daraus resultierenden Anforderungen an vorliegende Arbeit alle Informationen in angemessener Weise und sorgfältig recherchiert. Aufgrund struktureller und bildungspolitischer Faktoren ergab die Recherche und Sichtung der vorhandenen Fachliteratur fast erwartungsgemäß ein quantitatives und qualitatives Ungleichgewicht zugunsten englisch- und deutschsprachiger Publikationen. Dieser vergleichsweise lückenhafte Publikationsstand arabischer Fachliteratur im notfallmedizinischen Bereich, der symptomatisch für die insgesamt defizitäre rettungsdienstliche Situation im arabischen Raum ist, war zugleich Herausforderung und Ansporn, zu diesem Thema zu recherchieren und das Vorhandene in dieser Arbeit zusammenzutragen. Neben der Einordnung der Notfallmedizin im historischen Kontext, der Beleuchtung praktischer Aspekte des Rettungsdienstes und einer exemplarischen Momentaufnahme rettungsdienstlicher Strukturen in ausgewählten arabischen Ländern, soll vorliegendes Glossar Dolmetschern und Übersetzern nützliches Werkzeug bei der Vorbereitung und Ausführung von Aufträgen im medizinischen und notfallmedizinischen Bereich sein.:Inhalt EINLEITUNG 4 1.0 Untersuchtes Textkorpus 5 FACHLICHER TEIL 7 1.0 Geschichte des Rettungsdienstes 7 1.1 Ursprünge der Notfallmedizin 7 1.2 Ursprünge der Reanimatologie 9 2.0 Entwicklung des Rettungswesens in Deutschland 12 2.1. Gründung und Entwicklung der Hilfsorganisationen 12 2.2. Wandel und Entwicklung des Rettungswesens in den Kriegsjahren 14 2.3 Strukturelle Neuorganisation nach 1945 . 15 2.4 Reorganisation und Professionalisierung ab 1970 17 3.0 Charakteristika des Rettungswesens in Deutschland 19 3.1 Ausbildung ärztlicher und nichtärztlicher Mitarbeiter im Rettungsdienst 19 3.2 Land- und luftgestützte Rettungsmittel: Entwicklung und funktionale Differenzierung 22 3.2.1 Notarztwagen 23 3.2.2 Notarzteinsatzfahrzeug 24 3.2.3 Rettungstransportwagen 24 3.2.4 Rettungshubschrauber 24 3.3 Notärztlichen Einsatzmodelle 25 3.4 Zeitminimierter Transport oder präklinische Versorgung? Scoop-and-Run vs. Stay-and-Play 26 4.0 Grundlegende notfallmedizinische Maßnahmen im Rettungsdienst 29 4.1 Überwachung und Stabilisierung der Vitalparameter 29 4.2 Kardiopulmonale Reanimation 30 4.3 Polytrauma-Therapie 31 5.0 Rettungsdienstliche Strukturen im arabischsprachigen Raum 33 5.1 Libanon 33 5.2 Jordanien 35 5.3 Vereinigte Arabische Emirate 36 5.4 Palästinensische Gebiete 38 5.5 Zusammenfassung 40 ÜBERSETZUNGSWISSENSCHAFTLICHER TEIL 42 1.0 Einführung 42 2.0 Bedeutungsentlehnung und Lehnübersetzung 43 3.0 Strukturelle und phonetische Problematik der Entlehnung im Arabischen 45 4.0 Problematik einer fehlenden Vereinheitlichung 46 5.0 Lehnbedeutung und Polysemie 47 6.0 Fazit 48 GLOSSAR 50 1.0 Allgemeine Hinweise zum Glossar 50 2.0 Auswahlkriterien der Termini 50 3.0 Methodik der Recherche 52 4.0 Aufbau der Einträge 52 4.1 Ausgangssprachliche und zielsprachliche Einträge 52 4.2 Deskriptoren 54 QUELLEN

Introduction: The aging population is a rapidly growing demographic in the United States. Isolation, limited autonomy, and declining physical and mental health render many older adults vulnerable to elder mistreatment (EM). The purpose of this study was to assess the prevalence and correlates of EM among a sample of older adults using legal assistance services in Atlanta, Georgia. Methods: Researchers administered surveys to consenting older adults (aged 60þ) in 5 metro Atlanta community centers that hosted legal assistance information sessions as part of the Elderly Legal Assistance Program. The surveys screened for risk factors and prevalence of EM risk using valid and reliable measures and included additional questions regarding demographics characteristics and healthcare use behaviors. Results: Surveys were completed by 112 participants. Findings reveal that 32 (28.6%) respondents met the criteria for elder abuse / neglect risk; 17 (15.2%) respondents met criteria for depression; and 105 (93.7%) had visited a healthcare provider during the past 6 months. Conclusion: The rates of EM risk in this sample were higher than those previously reported in research. Findings support continued examination of unique risks that may be present among older adults who may be possibly facing legal issues. Additionally, the reported frequency of healthcare visits among participants reveals a promising opportunity to examine development of a more widespread EM screening approach to be conducted in non-emergency settings. Interdisciplinary collaboration is required to inform screening approaches that account for complexities that EM cases present. [West J Emerg Med. 2013;14(4):309–315.]

Introduction: Traumatic Brain Injury (TBI) remains a significant public health burden in the United States. Persons afflicted with more severe TBIs are usually admitted to an ICU, where they are at risk for a number of complications throughout their hospitalization. Recent literature has attempted to describe such complications from a cardiovascular perspective as part of a “cardio-cerebral syndrome.” We described the frequency of cardiac complications in the ICU among patients with a TBI and compared patients with and without measured cardiac dysfunction. We investigated the potential impact of cardiac dysfunction on in-hospital mortality. Methods: This was a retrospective review of a prospective cohort study in adult ICU patients with moderate-to-severe TBI (GCS≤12). We measured cardiac dysfunction using initial EKG echocardiography findings and peak serum troponin levels during hospitalization. Primary outcome was in-hospital mortality for patients with and without cardiac dysfunction using multivariable adjusted Cox Proportional Hazards Regression. Secondary outcomes examined the relationship between severity of brain injury and degree of cardiac dysfunction. Results: Ordinal logistic regression showed patients with more indicators of cardiac injury were significantly more likely to have greater brain injury as reflected by lower GCS scores (OR 0.76; 95%CI 0.58-0.99). There was a significantly increased multivariable adjusted risk of dying for each increase in measured cardiac injury (HR 2.41; 95% CI 1.29-4.53). Conclusions: Cardiac dysfunction was frequently observed in patients with TBI and we showed an association between increasing TBI severity and development of cardiac injury. Cardiovascular dysfunction was associated with an increased risk of in-hospital death. Adverse outcomes from TBI could potentially be mediated by cardiac injury, which could be used as a target for therapeutic intervention.

Opioid use disorder (OUD) is one of the most pressing public health problems of our time, with staggering morbidity, social impact, and economic costs. Prescription opioids play a critical role in the opioid crisis as they increase exposure and availability in the general population, making them an attractive target for much needed prevention and risk mitigation strategies. Opioid exposure, including legitimate prescription use, leads to a variety of physiologic adaptations (e.g. dependence) that may be leveraged to understand and identify risk of misuse. Mobile health (mHealth) tools, including wearable sensors have great potential in this space, but have been underutilized. Of specific interest are digital biomarkers, or end-user generated physiologic or behavioral measurements that correlate with events of interest, health, or pathology. Preliminary data support the concept that wearable sensors can detect digital biomarkers of opioid use and may provide clues regarding individual physiologic adaptations to opioid use over time. This dissertation follows a path though the exploration and refinement of these digital biomarkers of opioid use in various clinical use cases. Longitudinal data from individuals treated with opioids for acute pain will be explored through various machine learning models to detect opioid use and to explore patient and treatment factors that impact model performance. Next, a signal processing approach will be undertaken to explore the effects of opioid agonism in a different population of individuals- those presenting with opioid toxicity and precipitated withdrawal. Both approaches will be combined to further refine the digital biomarker capabilities, this time with a focus on the difference between opioid naive and chronic users. And finally, usability, facilitators and barriers to use of a sensor-based monitoring system for opioids will be evaluated through a qualitative lens. Taken together, theses data support the development of a smart technology, driven by empirically derived algorithms which can be used to monitor opioid use, support safe prescribing practices, and reduce OUD and death.

South African incidence of rape ranks amongst the highest worldwide. No direct policy exists for the emergency care provider management of rape victims in the pre-hospital setting. The pre-hospital exposure to rape cases is unknown as its health information system is not gender-based violence sensitive. In the absence of a clearly defined protocol, indiscretion in the emergency care treatment of rape victims remains undocumented. As a particularly vulnerable group globally, victims of rape are deserving of focused intervention. A qualitative, descriptive approach guided the research in which nine semi-structured voluntary interviews were held with emergency care providers, forensic medical practitioners and emergency consultants. Through a critical theory lens thematic content analysis was employed. University of Cape Town ethics approval was attained. The study found that pre-hospital providers lack knowledge and skills of rape victim identification and management but are desirous of evidence-informed guidelines for treatment and referral in a multidisciplinary approach. Educational and policy deficiencies are documented. The recommendations support a community of practice that is mutually inclusive of specialist rape-care centres, emergency department and pre-hospital providers in the interest of forensic emergency medicine. Due regard must be had for needs of practitioners at risk of vicarious traumatization from sexual assault management. Transformative curricula and responsive clinical guidelines are likely to redress any complicity of the health sector non-response to rape/sexual assault. This study is likely to benefit emergency care regulators, educators and researchers whose professional interest is to promote responsivity of the health system to rape.

Background: Medical student involvement in clinical care of obstetrical emergencies is limited. Wearable technology, namely Google Glass, has been used to enhance the simulation experience for trainees at our institution. We present a pilot study that examines the utility of this technology in medical students’ education through remotely-conducted exercises in obstetric emergencies. Materials & Methods: A total of thirteen medical students accepted the opportunity to participate in an obstetric emergencies training exercise with remote monitoring. Students wore the Google Glass device while participating in two simulated obstetrical emergencies: shoulder dystocia and vaginal breech delivery. A remote instructor monitored the students’ performance and gave verbal instructions during the simulation. Students then filled out a questionnaire grading the effectiveness of the exercise. Results: Of all participating students, 55% reported Glass extremely valuable for their education. None reported it as not being valuable. 15% reported that Glass distracted them in their simulation activity. 100% of participants reported it being more than “successful" in its potential to improve emergency obstetric care. 55% reported that Glass or a similar device is “extremely likely” to be incorporated into medicine. None reported that it is unlikely to be used in the future of medicine. Conclusions: Wearable technology has the potential to provide improved learner experience. This technology can be successfully used to provide student exposure to simulated emergencies. Further studies evaluating the participation of students and other learners in simulated obstetrical emergencies are needed to determine how effective wearable technology can become in medical education and ultimately patient care as well.

Background: Tension pneumothorax is a condition with frequent fatal complications. This condition is caused by a disruption in the lung - that creates a one-way valve allowing air to accumulate in the pleural space. The fatal complication is the prevention of blood returning to the right side of the heart - due intrathoracic pressure compressing the right atrium. The patient can exhibit symptoms of dyspnea, tachypnea, tracheal deviation, jugular venous distention, subcutaneous emphysema, and shock that can lead to rapid deterioration and death. Case Report: We report a case of massive subcutaneous emphysema complicating tension pneumothorax management. The patient is a 20-year-old male who presented to the emergency department with chest trauma and was in extremis with diffuse severe subcutaneous emphysema. Due to the distorted anatomy, airway management and chest decompression were performed with nonstandard techniques/equipment resulting in rapid patient stabilization. After 4 days in the hospital, he was discharged home with no deficits. Discussion: Many providers do not have the proper equipment or training to treat patients in this extreme condition. CT images demonstrate the anatomical distortions in this case and the increase in size required for invasive life-saving devices. Images demonstrate where many commercial 14 gauge angiocaths and cricothyrotomy kits will not suffice (due to distortion in the anatomy), and these should not be relied on solely. Conclusions: While trauma carts frequently maintain (1.75 - 2 inch) 14 gauge angiocaths, they should also have military grade angiocaths that are 3.25” in length, which will work in most cases. Some, but not all, military-grade cricothyrotomy kits, or individually assembled kits, have 6.0 endotracheal tubes and come with a bougie and cricothyrotomy hook which would have been sufficient in this patient. Prehospital and hospital healthcare personnel should be prepared for similar patient encounters.

Every year, conflicts and natural disasters affect millions of people worldwide. However, the resources to assist those affected are perpetually insufficient. When emergencies strike, assistance organizations must decide where to prioritize their limited resources to reduce as much mortality and suffering as possible. At the start of their emergency response activities, organizations typically make three key decisions: 1) determine if they will respond 2) prioritize/triage the needs of the affected population; and 3) choose first response programs to implement. Many studies and authors note that these decisions are often based on insufficient evidence and personal judgement. This dissertation argues that we, as emergency responders, can do better. Epidemiologic methods can empower us to make better decisions based on better measurement, analysis, and evidence – improving outcomes for emergency affected persons, globally. This dissertation provides three examples of epidemiologic methods being used to inform critical emergency response decision points. Aim 1 addresses the first emergency response decision: prioritizing the most severe emergencies for response programing. Aim 2 focuses on the second emergency response decision: how can responders most accurately prioritize the needs of affected persons by using needs surveys, given the potential that needs vary by gender or age. Aim 3 examines the third decision: which response programs to implement, by summarizing the evidence base for the effectiveness of standard emergency programs. Methods In aim 1 I facilitated a panel of outbreak specialists from a leading emergency response organization to develop, test, and validate a new measure for the classification of outbreaks. I used classical scale development methods, including both qualitative and quantitative procedures. In aim 2 I used data from 12 emergency needs surveys to examine a common assumption that reported needs and experiences vary based on the gender and/or age of the respondent. I conducted both individual analyses of each study as well as a set of meta-analyses examining the prevalence differences found between gender and age sub-groups. In aim 3 I conducted a systematic scoping review of the evidence of what programs are effective in acute emergency settings. I searched six academic databases as well as eight sector-relevant grey literature databases -focusing on evidence for standard emergency interventions. Results In aim 1, a new outbreak classification measure was successfully developed based on inputs from the expert panel and a compiled dataset of indicators in global outbreak emergencies. The measure allows for the immediate (within two hours) classification of outbreaks. The expert panel participated in qualitative exercises where they developed a construct of ‘scale and severity of outbreak emergencies.’ This construct had four sub-dimensions, and a scale was developed to measure each sub-dimension, and then combined into a single measure. The content validity, criterion validity, construct validity, and reliability were examined for the measure. Criterion validity was based on a strong (0.87) correlation between the new outbreak measure and a ‘gold standard’ ranking of outbreak emergencies created by a group of emergency decision-makers (‘judges’). Similarly, construct validity was based on the measure performing as predicted when compared to measures of a similar/dissimilar construct, (convergent and divergent validity). The case for reliability was made using intraclass correlations between the new outbreak measure and the ‘gold standard’ measure (a robust result of a 0.87 using an ICC 3, 1), as well as comparing how well the outbreak measure worked alongside the conflict and natural disaster measures (another robust finding of 0.91 using an ICC 3, 1). In aim 2, I found that emergency affected persons of various gender or age groups very rarely differ in their responses to needs and experience questions in emergency surveys. When searching for differences in how gender or age groups report their households’ top three needs, meaningful differences in individual studies were found 6% of the time. When a meta-analysis of the same data was conducted across all needs questions in all 12 surveys, no meaningful differences were found between how either men or women report needs, or how different age groups report needs. Responses to questions about experiences (rather than needs) in emergencies were slightly more likely to vary by gender or age group. The meta-analysis of experience questions showed that across the 12 assessments differences in how gender or age groups experience emergencies were extremely rare (less than 4% of questions showed a meaningful summary prevalence difference). In aim 3 I identified 43 programs that are commonly implemented in acute emergency response. My scoping review searched for any studies that rigorously evaluated the impact of one or more of these programs. My search identified 4,005 unique studies; I screened them all for eligibility, resulting in only four studies that met all inclusion criteria. Thus 39 of the pre-identified, common emergency programs have no published evidence of their effectiveness in acute emergencies. The remaining four, each have one study in one context that demonstrates at least one positive effect of the program. Conclusion This dissertation provided evidence that epidemiologic methods can help solve problems, answer questions, and improve the allocation of resources in acute emergencies. While each aim focused on a unique decision point within acute emergency responses, they all contended with similar difficulties, such as incomplete and poor-quality data and a lack of shared definitions for what data points are relevant in decision-making. Yet in all three aims I found other similarities as well: there are relevant data available; and there are effective methods available that can answer many of our questions.